PSOW Individual Decisions

Mrs X complained that Swansea Bay University Health Board failed to respond to the complaint she submitted in July 2024. The Ombudsman found that the Health Board had not provided a final complaint response. She said this caused uncertainty and frustration for Mrs X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 6 weeks, issue the complaint response which will include an apology and explanation for the delays, and offer a £200 financial redress payment in recognition of the delays and for the time and trouble.

Mrs A complained about the care and treatment her late father (Mr B) received from Swansea Bay University Health Board. The investigation considered whether Mr B’s blood pressure was appropriately managed whilst he was an inpatient between 26 December 2022 and 4 January 2023, and whether, the decision to discharge him without re-instating ramipril (a type of antihypertensive medication, called an angiotensin-converting enzyme (“ACE”) inhibitor which works by widening the blood vessels making it easier for the heart to pump blood around the body), with a plan for review with the GP in 7 to 14 days, was clinically appropriate. The investigation found that Mr B’s blood pressure was appropriately managed during admission. Given Mr B’s renal deterioration, it was appropriate that his antihypertensive medication was withdrawn, until he had begun to recover. The decision to recommence lacidipine (an antihypertensive medication that works by relaxing the blood vessels) during admission, but to continue to withhold ramipril was also appropriate. The decision to discharge Mr B without re-commencing ramipril was clinically appropriate. It is normal and good clinical practice to defer blood pressure monitoring to a patient’s GP following discharge. The error in the discharge summary did not cause, and was unlikely to have caused, a clinical injustice to Mr B. The complaint was not upheld.

Cwynodd Mrs A am y gofal a ddarparwyd gan y Feddygfa i’w phartner diweddar, Mr B, y diwrnod cyn iddo farw. Fe wnaethon ni ymchwilio i weld a oedd y Feddygfa wedi methu ag asesu a rheoli poen yn y frest Mr B yn briodol ar 27 Chwefror 2024. Canfu’r ymchwiliad fod y gofal a ddarparwyd i Mr B gan y Feddygfa ar 27 Chwefror o fewn yr ystod o ofal clinigol priodol. Ni ellid yn rhesymol ddisgwyl i’r meddyg teulu a welodd Mr B ragweld y byddai Mr B yn debygol o farw o ganlyniad i achos cardiaidd o fewn 24 awr, yn seiliedig ar ei symptomau ar adeg yr ymgynghoriad. Yn unol â hynny, ni chadarnhawyd y gŵyn.

Miss A complained that the Health Board prescribed and administered the incorrect dose of epilepsy medication to her 3-year old daughter when she attended the Emergency Department. Miss A said that despite having evidence of the prescribed medication, the Health Board said that there was no record of a prescription being given to her daughter. Miss A said that the Health Board did not respond to her request for a meeting to discuss her complaint. The Ombudsman decided that the Health Board had not explained to Miss A that medication was supplied by the Pharmacy for inpatient use. The Health Board had not identified that seemingly the inpatient medication was taken home when Miss A’s daughter was discharged, or that Miss A had raised concerns that the dose was incorrect. The Health Board said that it tried to contact Miss A to arrange a meeting but had been unsuccessful. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to within 4 weeks provide a written response to Miss A, to offer an apology for any confusion caused between inpatient and take home medication, to confirm if any medication administered was at the correct dose, to establish what happened with the medication and remedy any issues identified, and to offer a meeting to discuss the complaint.

Mr X complained regarding the treatment Mrs X received while at hospital and how his concerns had not been addressed in the Health Board’s response. The Ombudsman found that, while the Health Board had responded, the response was lacking in detail and did not directly address the concerns Mr X raised. The Ombudsman said this caused uncertainty and frustration for Mr X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 4 weeks, offer an apology to Mr X for not addressing his concerns in the complaint response and explain why this happened. The Health Board also agreed to issue a new complaint response that will address Mr X’s concerns.

Miss S complained about the care provided to her father, Mr L, during his admission to hospital in May 2024. The Ombudsman began an investigation into whether Mr L’s risk of sepsis was recognised and managed appropriately, and whether his sepsis was diagnosed promptly. In responding to the Ombudsman about the complaints subject to investigation, the Health Board confirmed that it had identified delays in the investigation of the possibility that Mr L had sepsis and in treating him once sepsis was identified. The Health Board agreed to formally apologise to Miss S for the failings it had identified and outline what measures it would implement to prevent similar failings occurring in future. It also agreed to forward this matter to its Redress team to consider whether and to what extent those failings caused harm to Mr L, following a process that is line with requirements under regulation 26 of the NHS Concerns, Complaints and Redress Arrangements (Wales) Regulations 2011. The Ombudsman considered that it was appropriate to settle the complaint on the basis of this action.

Mrs A complained to Swansea University Health Board regarding the treatment and care she received and how she had not had a complaint response. The Ombudsman found that Mrs A had complained to the Health Board 7 months ago and had still not received a formal complaint response. The Ombudsman said this caused frustration and uncertainty for Mrs A who had a lot of unanswered questions. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman gained the Health Board’s agreement to, within 4 weeks, provide the full compliant response, including an apology and an explanation as to why there was a delay.

Mrs A complained to Swansea University Health Board regarding the treatment and care her deceased mother had received and how she had not had a complaint response. The Ombudsman found that Mrs A had complained to the Health Board 8 months ago and had still not received a formal complaint response. The Ombudsman said this caused uncertainty for Mrs A who had lost her mother. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman gained the Health Board’s agreement to, within 4 weeks, provide the full complaint response, including an apology and an explanation as to why there was a delay.

Miss X complained that Swansea Bay University Health Board had failed to respond to the complaint she made to it in March 2025.The Ombudsman found that there had been a delay in the Health Board responding to Miss X. The Ombudsman said this caused frustration to Miss X and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise and explain the reasons for the delay and to issue its complaint response to Miss X within 4 weeks.

Mrs A complained that the complaint response from Swansea Bay Health Board did not adequately address her concerns. Mrs A contacted the Health Board but had not received a further response. The Ombudsman found that, although the Health Board had agreed to provide a further complaint response, it had not done so. Mrs A was inconvenienced by the delay, which had caused her frustration. The Ombudsman decided to settle the complaint without investigation. The Health Board agreed to, within 4 weeks, provide Mrs A with a further complaint response together with a written apology for the delay.

Ms X complained to Swansea University Health Board regarding the care and treatment she received and how she has not had a complaint response. The Ombudsman found that although Ms X complained to the Health Board over a year ago, she has yet to received a formal complaint response from it. The Ombudsman said this caused uncertainty and frustration for Ms X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 4 weeks, provide the full complaint response, include an apology and explanation as to why there was a delay of 12 months and to offer a£150 financial redress payment in recognition of the delays.

Mrs C complained about the care and treatment her late mother, Mrs A, received from Swansea Bay University Health Board (“the First Health Board”) between 18 and 22 March 2023. Her concerns include the delay in administering regular medication to Mrs A prior to the Transcatheter Aortic Valve Implantation (“TAVI” – a procedure that improves the blood flow in the heart by replacing an aortic valve) procedure between 18 and 22 March 2023. She questioned whether Mrs A was fit enough to undergo a TAVI procedure on 22 March 2023 and if the TAVI contributed to Mrs A developing pancreatitis (inflammation of the pancreas). Mrs C also complained about the care and treatment Mrs A received from Hywel Dda University Health Board (“the Second Health Board”) and whether there was a missed opportunity to treat Mrs A for sepsis (a serious life-threatening reaction to an infection) during her hospital admission between 28 April 2023 and 6 May 2023. The Ombudsman’s investigation in relation to the First Health Board found that, whilst there was a delay in administering medication to Mrs A, she was appropriately medicated and any delays did not materially affect her care. The investigation also found that Mrs A was fit enough to undergo the TAVI procedure and that there was no causal link between the TAVI procedure and the development of Mrs A’s pancreatitis. Mrs C’s complaint was not upheld. With regard to the Second Health Board, the investigation found that there was no evidence of a missed opportunity to treat Mrs A for sepsis between 28 April and 6 May 2023. The Ombudsman did not uphold this complaint.

Mrs C complained about the care and treatment her late mother, Mrs A, received from Swansea Bay University Health Board (“the First Health Board”) between 18 and 22 March 2023. Her concerns include the delay in administering regular medication to Mrs A prior to the Transcatheter Aortic Valve Implantation (“TAVI” – a procedure that improves the blood flow in the heart by replacing an aortic valve) procedure between 18 and 22 March 2023. She questioned whether Mrs A was fit enough to undergo a TAVI procedure on 22 March 2023 and if the TAVI contributed to Mrs A developing pancreatitis (inflammation of the pancreas). Mrs C also complained about the care and treatment Mrs A received from Hywel Dda University Health Board (“the Second Health Board”) and whether there was a missed opportunity to treat Mrs A for sepsis (a serious life-threatening reaction to an infection) during her hospital admission between 28 April 2023 and 6 May 2023. The Ombudsman’s investigation in relation to the First Health Board found that, whilst there was a delay in administering medication to Mrs A, she was appropriately medicated and any delays did not materially affect her care. The investigation also found that Mrs A was fit enough to undergo the TAVI procedure and that there was no causal link between the TAVI procedure and the development of Mrs A’s pancreatitis. Mrs C’s complaint was not upheld. With regard to the Second Health Board, the investigation found that there was no evidence of a missed opportunity to treat Mrs A for sepsis between 28 April and 6 May 2023. The Ombudsman did not uphold this complaint.

Mrs A complained about the Health Board’s Mental Health Services and the failure to provide support to her son during a mental health crisis. Mrs A was dissatisfied with the Health Board’s response to her complaint. The Ombudsman found that the complaint response did not adequately address Mrs. A’s concerns. The Health Board could have, as part of its investigation of her complaint, sought the patient’s consent in order to provide a more detailed response. This caused inconvenience and frustration for Mrs A. The Ombudsman decided to settle the complaint without an investigation. The Health Board agreed to, within 6weeks, seek consent from the patient and provide Mrs A with a further, more detailed, complaint response addressing all her concerns.

Mr A complained about an equipment malfunction (cannula detachment) during eye surgery which caused him to require further treatment. He was concerned that the Health Board’s formal response to his complaint gave general information about the procedure. It did not contain any specific detail of the action taken in his case, nor any reference to the content of his medical records. Having considered the complaint, the Ombudsman noted that the Health Board’s complaint response should have been specific to what happened in Mr A’s case and referred to the content of his medical records. The Health Board agreed to carry out the following action within 4 weeks: Provide a further complaint response to Mr A, specific to the procedure as documented in his clinical records. This should include detailing what happened during the procedure, the action taken to mitigate the known risks and who was present when the procedure was undertaken.

Mrs A was concerned that a wound infection she developed in her groin following surgery to remove vaginal mesh was a result of the inpatient care and management she received following the surgery. The Ombudsman’s investigation focused on whether the post-operative care provided to Mrs A between 23 and 27 August 2023 (when she was discharged) was clinically appropriate. The Ombudsman’s investigation found that Mrs A’s inpatient care and management, including the timing of the removal of her drains, was clinically appropriate. The decision to discharge her was also of an acceptable clinical standard, as Mrs A was clinically stable and the prescribed discharge medication was suitable. The Ombudsman found that the post-operative infection was an unfortunate but recognised complication of the surgery Mrs A underwent and was not caused by any shortcomings in the care provided by the Health Board. The complaint was not upheld.

Mrs X complained that Swansea Bay University Health Board failed to respond to the complaint she submitted in March 2025. The Ombudsman found that the Health Board failed to formally respond to the complaint. The Ombudsman said this caused uncertainty and frustration for Mrs X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement, within 4 weeks, to provide the complaint response that will include an apology and explanation for the delay and an offer of a £50 redress payment in recognition of the delays.

Ms X complained that a GP Practice in the area of Swansea Bay University Health Board had failed to respond to the complaint she made to it in July 2024 about the care and treatment provided to her late mother. The Ombudsman found that there had been a significant delay in the Practice responding to the complaint. The Ombudsman said that the delay caused frustration to Ms X. The Ombudsman found that the Practice had written to Ms X in August 2025 and apologised to her for the delay and provided an explanation for it in a letter. The Ombudsman decided to settle the complaint without a formal investigation. The Ombudsman sought and gained the Practice’s agreement to issue the complaint response and to offer Ms X a redress payment of £250 in recognition of the significant delay in issuing the response within 6 weeks.

The Ombudsman’s investigation centred on whether: a) There was an unnecessary delay in Swansea Bay University Health Board (“the Health Board”) arranging Mr A’s surgery from January 2022 onwards. b) The Health Board provided Mr A with regular and appropriate updates. The investigation found that there was an unnecessary delay, especially in 2023, in the Health Board arranging Mr A’s surgery. Even taking into account the extended accounting/ordering and purchasing process, as the chosen manufacturer was a new supplier, Mr A potentially could have had his operation almost a year earlier, and possibly even earlier than this. Mr A’s surgery eventually took place in February 2025. The Ombudsman concluded that the failings that led to the unnecessary delays in Mr A’s operation amounted to maladministration and caused service failings. The delayed procedure also resulted in Mr A suffering an injustice. Mr A referred to the impact on him which included a deterioration in his mental health. This part of Mr A’s complaint was upheld. The Ombudsman identified communication shortcomings on the part of the relevant Department’s Manager. As a result, this adversely affected the appropriateness and regularity of the updates that the treating consultant and his secretary provided to Mr A. In the absence of communication to the contrary, their expectation was that the order was being progressed by the Manager and the evidence shows that this was not always the case. The Ombudsman concluded that the communications failings were again maladministrative and contributed to service failings which caused Mr A an injustice. This is because it added to Mr A’s frustration and his deteriorating mental health which he referred to. This aspect of Mr A’s complaint was also upheld. The Health Board accepted the Ombudsman’s recommendations which included making a written apology to Mr A and a financial redress payment of £750. The latter was in recognition of the distress and frustration caused to

Ms A complained about care provided by the Health Board to her late partner Mr B. The Ombudsman’s investigation considered whether the Health Board provided prompt and appropriate care to Mr B at Morriston Hospital after staff were alerted to his medical emergency. The investigation found that it was unlikely that there was sufficient evidence to determine whether maladministration of service failure occurred. However, the Ombudsman was concerned that the available evidence indicated that there may have been some confusion about where to find a defibrillator in order to provide emergency care to Mr B in the hospital car park. It also appeared that not all staff involved in the response were fully aware of the details of the Health Board’s policy for responding to medical emergencies on the grounds of the hospital, but not in hospital buildings. The Ombudsman considered that there was scope for lessons to be learned to improve the way staff on the site respond to similar emergencies in the future. The Health Board agreed to carry out a review within 3 months of current policies and procedures for responding to cardiac arrest or similar clinical emergencies on the grounds of Morriston Hospital but not inside the hospital buildings. It will carry out this review with reference to the care provided to Mr B. The review should have input from the Emergency Department, staff working at the ambulance triage station and any other relevant staff. It should include consideration of whether sufficient guidance is available to relevant staff in terms of roles and responsibilities and in relation to where a defibrillator will be sourced from. It should also consider whether any other specific learning points can be identified that might lead to a better co-ordinated response should a similar scenario occur again. The Ombudsman considered that, taking into account the limitations of the available evidence, it was appropriate to settle the complaint on the basis of the above action

Mr C complained on behalf of his wife, Mrs C, about the care and treatment she received from a dental practice in the area of the Health Board. Mr C complained that dental treatment for Mrs C’s fractured front tooth and crown was urgent and should not have been dealt with on a private care basis. Specifically, the investigation considered whether the decision not to offer a timely NHS appointment was made appropriately on 5 February 2024. It also considered whether the decision to decline Mr and Mrs C any further dental care on an NHS basis was appropriate. The Ombudsman found that the decision not to offer an urgent NHS appointment on 5 February 2024 was made appropriately owing to the presenting symptoms not requiring urgent care or treatment. The offer of a routine NHS appointment in April was acceptable. It was also found that there was no maladministration in relation to the decision by the Practice to decline Mr and Mrs C any further dental care, based on a breakdown in the relationship. The Ombudsman did not uphold either complaint.

Mr and Mrs A complained that the Health Board delayed offering an appointment to Mr A to discuss the results of his colorectal cancer scan. He had recently finished treatment and the post treatment scan was carried out in January 2024. He was initially offered an appointment in April and, whilst this was subsequently altered to an earlier appointment, Mr A was not informed of the results of the scan (which showed the cancer had spread) until 20 March. Sadly Mr A died during the investigation of his complaint. The Ombudsman upheld the complaint that there was a delay in offering an appointment to Mr A to discuss the results of his colorectal cancer scan. Although the delay did not affect the clinical outcome for Mr A, it would have added unnecessary stress and uncertainty at an already very difficult time. He also should have been informed that his cancer had spread at the earliest possible opportunity. The Health Board agreed to apologise to Mrs A for the identified failings, and, within 3 months, to review its oncology administrative system to ensure it was sufficiently robust to highlight where patients have not attended a review consultation following a multidisciplinary (MDT) discussion.

Miss C complained on behalf of her late father, Mr A, about the care and treatment he received from Swansea Bay University Health Board (“the Health Board”) when he was admitted to hospital between 1 November and 9 December 2022. Specifically, the investigation considered whether the care and treatment provided to Mr A was clinically appropriate, given the diagnosis of a traumatic intracranial haemorrhage (bleeding within the skull due to a head injury), and whether the nutritional support provided to Mr A was also clinically appropriate. The investigation found that, overall, the fundamental clinical management of Mr A was appropriate. However, there were flaws in anticoagulation management protocols and in the implementation of his Do Not Attempt Cardiopulmonary Resuscitation (“DNACPR”) order. Despite this, these failings did not contribute to Mr A’s death. This part of the complaint was not upheld. However, the nutritional screening of Mr A was found to be below the required standard. The screening was found to be often inaccurate due to his weight not being taken and the recording and recognition of his poor dietary intake. In addition, there was a missed opportunity to refer Mr A to a dietitian at an earlier stage. This was an injustice to Mr A as his nutritional needs were not adequately met in the latter stages of his life. This part of the complaint was upheld. The Ombudsman recommended the Health Board apologise to Miss C, share the report with the nursing team involved in Mr A’s care, review its protocol for referrals to a dietitian and review its protocol around mental capacity assessments. The Health Board agreed to implement the recommendations within the specified timeframes.

Mrs A complained that the Health Board had failed to provide a complaint response – nor any substantive updates – to the complaint about her late husband’s care, which she had submitted over a year ago. The Ombudsman found that the delay in responding to the complaint was excessive and had exacerbated the distress Mrs A felt at the loss of her husband. The Health Board agreed to issue to Mrs A its full complaint response letter, an apology for the delay and £250 in recognition of the poor complaints handling, within 20 working days. The Ombudsman considered this to resolve the complaint and did not investigate.

Mrs A raised concerns that staff failed to properly assess and treat her mother’s (Mrs B) leg ulcers following admission to hospital. These ulcers had previously been managed well at home through daily visits by district nursing staff. Swansea Bay University Health Board (“the Health Board”) had accepted some shortcomings in the leg ulcer care but was of the view that no harm had resulted from these. After the complaint to the Ombudsman, the Health Board reconsidered its initial decision that no harm had been caused to Mrs B. This was due to photographs from the District Nursing department which were provided by Mrs A. On the basis of these, the Health Board referred the issues raised to its Legal Department under the redress process. The Ombudsman did not therefore consider the clinical aspects of this complaint. However, the Ombudsman noted that poor communication with Mrs A about her complaint, and the Health Board’s failure to obtain and consider relevant information (District Nursing clinical photographs) in investigating the complaint unnecessarily delayed and escalated the complaint. The lack of availability of Tissue Viability nursing staff was also a concern. In recognition of the poor handling and investigation of Mrs A’s complaint, the Ombudsman upheld the complaint. The Ombudsman made several recommendations, including that the Health Board should: · Apologise to Mrs A in writing. · Review its current Tissue Viability nursing provision. · Review the complaint handling in this case to ensure that all appropriate information proportionate to a complaint investigation is obtained prior to a decision being reached.